| Lightspace, Inc. | |
|
1275 Big Flat Rd Missoula MT 59804-9217 | |
| (406) 728-1413 | |
| Not Available |
| Full Name | Lightspace, Inc. |
|---|---|
| Speciality | Psychologist |
| Location | 1275 Big Flat Rd, Missoula, Montana |
| Authorized Official Name and Position | Jodi Leslie (PRESIDENT) |
| Authorized Official Contact | 4067281413 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Lightspace, Inc. 1275 Big Flat Rd Missoula MT 59804-9217 Ph: (406) 728-1413 | Lightspace, Inc. 1275 Big Flat Rd Missoula MT 59804-9217 Ph: (406) 728-1413 |
| NPI Number | 1497803084 |
|---|---|
| Provider Enumeration Date | 01/08/2007 |
| Last Update Date | 08/22/2020 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1497803084 | NPI | - | NPPES |
| 0000253164 | Medicaid | MT | |
| 944653 | Other | MT | LCPC, BLUE CROSS BLUE SHI |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YP2500X | Counselor - Professional | 960 (Montana) | Primary |
| 103T00000X | Psychologist | 115184-2501 (Utah) | Primary |
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